1 day in Taipei part 1 - medical ethnic/law/quality CME credits

On the day I brought Yun to ED for her swelling forearm. I was called by our secretary...She told me that the CME system had changed asked me how many medical ethnic/law/quality CME credits that I had. She was unable to assess my database as I had change my password. She showed me a circular and I was not happy after reading it...All of the doctors are required to renew their Practice License(PL) by 2009-4 and I will need 18 of the mentioned credits to be eligible for renewal.

The PL is something like APC (anual practicing certificate) in Malaysia. Unlike the APC, the PL is valid for 6 years. For renewal, those with specialist qualification will need 300 credits which was recognized by each specialty body. For the rest of GP, they need 180 credits. The system has been imposed for a very long time, until the SARS period. There were some doctors who refused to serve and took leave(absconded to be precised) - they said they were not trained in the field of internal medicine .. Such unethical act had later lead to the development of PGY training system. The Health department had also imposed a 18 medical ethnic credits requirement for PL renewal aiming to re-educate the doctors.

It was SARS period when I came back here. My PL was due in 2009 and according to the rule my PL will auto-renew to a later date which will be same as my specialist certificate expired date( 6 years from the day I passed )which is 2012 - a long long time before I need to gather my 18 credits. Unlike other CME - the ethnic credits were very difficult to get. The session is usually 1.5 to 2 hrs per credits. Each session is only 1 credits only unlike other credits which are 2-3 hrs/5 credits. I though it was a long way to go and I had 7 credits for the past 4.5 years. Averagely one should have 3 credits per year...The latest rule however had changed and I had a death line of 1.5 years to get my 11 credits...a short time for me to go for a big load of credits...

It bothered me a little when I heard the news...and when I reached home and I arranged my stuff. I saw this letter from the medical associated which had arrived sometimes ago. I didn't bother to open it and I opened it and my  problem was solved. There was this annual conference on Fri, Sat, Sun and it offered 9 credits per 6 hrs in 1 days. But I will need to go to Taipei...I was off on Friday and what the heck...I decided to go...I will have 16 credits after this conference....

Common condition, but uncommon patient...

7 yrs old girl with rt forearm swelling after fell down in the school yesterday afternoon...

common history and obvious xray....I was the ED doctor but the patient was Yun.....

I was on working that day and due for home on next day noon; Ving called me and told me that Yun's wrist was swelling after she woke up from her afternoon nap. She was playing and tripped over ? bar. She is due for her 1st exam the next day and she went to played in the play ground during her recess time...I grumbled a little and asked detailly about her injury.... Ving told me that the swelling was over the "wrist" side and it was ok when she arrived home...I thought should not be any fracture, fracture at the wrist side mostly cause instant swelling. I told Ving to gave her some syrup panadol and ice-packing. The pain was better but the swelling did not improved.
The next day was her exam and I went off at noon. It was Tuesday and she was went off by 3:00pm. I  told Ving that I would go to the school and had a look of her injury. When I saw her she was preparing to take her afternoon nap. I nearly fainted - the swelling was not over the wrist but at the distal third of forearm and it looked deformed...definitely a fracture. I took a leave for her and brought her room. We changed and brought her back to my hospital. It was one of the longest drive - I was post 24 hrs shift and took a 30 min drive from hospital and now returning to there again.
As I had expected - the xray showed a fracture : luckily was a greenstick one...I brought her to the ortho OPD and referred her to my colleague. My colleague suggested a cast with a slight CMR(Closed manual reduction)...Yun was lucky as the next cast(which was much lighter and does not required a cutter for removal had just arrived 1 hrs ago). Water resist pad was also use to prevent itchness...I was dread tired that evening...but everything was worth....I considered Yun as very lucky - at least no pin required.

I recalled the fracture I had 30+ years ago..,...I was studying in Kindergarten. There were 3 of us. We placed ourself inside a hula hoop: and started to run. I fell and knocked over my left elbow.. instant swelling and I was brought to local hospital and later referred to Assunta hospital. An ops was done and closed reduction was made...I was put on cast for the next 1+ months...The cast was those traditional one, darn heavy and the itchness was so stressful....I am happy Yun did not have to undergo that...

Disaster exercise Final day

I got a good sleep and we arrived at the site at 9:30am

on the way to the airport, there was this piece of paper who flied and stucked itself over the windshield and wiper...it was "golden" paper for the death... what a bad start for the day...

...The drill started by 10:20am and ended by 11:30am. I was told by the sister in charge of my area that another doctor would join me in the afternoon during the final presentation. I was a  little pissed off - the doctor who would join us was from the govt hospital site, appearently, he was on the list but decided to appear on the final day only. For us not from the govt site - we did not enjoy such luxury --- from D1 I was there... we would told need to be there for the whole 3 days !!!

The national DMAT(southern region) team ... Medical tent : double layer..and fully equiped...	The national DMAT team in their uniform... they are based 170+ km away from this airport...

the is the last drill - we were given some matress and even strecther for transport... the right tent was the red zone - more severe patient... it was manned by the local DMAT team.

this was the small room we waited before we enter the scene..

The final presentation started earlier and it was over by 3:00pm - I was very tired then , even though I had a good call last night...

This was real action scene...

 

This was the XXX part - we were requested to gather around in row and "listen" opinion from 2 evaluating officer. One of them is a Colonel - deputy division commander, the other one was ED director from a prestige hospital. We looked like primary school students - standing under the sun for a good " lecture"...

Finally at the end of the day, I saw rainbow...what a day....

Disaster exercise D2

We were there by 9:30am as ordered. By 10am, we were informed that there was a change of plam. We would enter the scene by running in instead of sending in by ambulance. They had prepared a room for us - store room for airlines just beside the boarding gate. Luckily it was air-conditioned, evenif it is now autumn day but very windy around this area,but still southern part of this country could heat up to 29 degree at noon.

There was a drill in the morning and by 11:00am, the lunch box arrived. We took our portion and waited till afternoon for the 2nd round of drill.

	this is the medical tent for the moderate injured patient - no bedsheet, no mat for the patient to rest...
	more waiting time - you can see the famous buddist organization was also requested to participate...

 

There were patients for us to manage at the afternoon drill, but somehow the organising committee was not satisfy and called for a 3rd drill. It was 3:30 pm we were reluctant to do it...according the schedule there was only 4 drill prior to the final presentation. The last drill was over by 5:00pm and I reached hospital by 5:50pm barely made it to took over from my colleague. I was cursing on the way back as the committee had anounced that we would be havinv another drill tomorrow morning - according to the schedule, we would only need to report  by noon for the final presentation of D3.....

The stage	The tent for "black" bag....

The call for the night was extremely good - there was only 1 patient at 2:30pm from 12MN to morning 7am...I got a good sleep.

Disaster exercise D1

It was a good call for me, I got a good 3 hrs sleep...

We arrived at the scene at 9:30am....reported and took a seat the waiting lounge...
A short briefing was done and the leader frome each unit were called to the meeting room. As the doctor, I was supposed to be the leader but I "asked" one of my nurse to took the position...
The rest of us waiting at the lounge

	These were not flight passengers - I thought they were initially. They were local residents who was called to act as casuatlies(I heard they got pay a few hundred NT per day for the act).
	The briefing
	1 hrs post reporting - waiting...
	2 hrs and still waiting...

 

By 12:15 noon - the lunch box came...we took a lunch box and fill up my grumbling stomach. By 1:30pm. The drill started. We were asked to sit in the ambulance and waited for command to enter the scene. 16 ambulances from different unit waiting at a corner. The engines of all 16 ambulance were running producing enough pollution and what a waste of petrol. I slept in the car for 40 min and we were called.

we were standing in the air field, under the sun...	16 ambulances...I wander in an actual disaster could me mobilized so many ambulances in a short time ?

 

Later we were gahtered to the lounge again and change of plan was done after a short meeting(and waiting time for us of coz). By 4:00 pm, we were dismissed and I returned to my house in a very tired state...

Disaster exercise....Prelude

There was this worst earth quake in 1999 Nov 21st. Casualties and loss of properties beyond imagination..The govt had started to set up their disaster response system based on the US version. But thank god, it was never initiated. The most recent natural disaster was also an earthquake which hit the southern part of taiwan( approx. 70km from my house.) happened on 2006-12-26. I was doing my passing over in ED then.....Some building collapsed, and some life lost...

10 months later, the local govt had decided to do a drill for this earth quake scenario...I become part of it...my colleague was supposed to attend it but as he was sitting for his EM board exam, I took over his place instead. However the exercise was postponed twice and it will be officially done tomorrow. For the past 2 days, I had been to this airport which located at the southern part of Taiwan. It is actually not suitable to deo it in a small airport - but this airport is hardly use - 2 flight per week and sometimes flight postponed due to strong wind. Any small object in the run way might cause a disaster...Anyway, it was done there...

I went to the exercise with 2 nurses+ambulance+1driver. I was the in charge of the yellow area(mod-light injury). The exercise was organized by the county health department. But the army, the national DMAT(south) and regional DMAT were also involved. ...

It was a disaster for me though, the exercise was 70 km from my house, 50 km from my hospital. I will go to the hospital and joined the team and travel to the airport by hospital ambulance.

The schedule for me is terrible....:
Mon night on call
Tue AM - pre exercise 1    PM - pre-exercise 2
Wed AM- pre-exercise 3   PM - pre-exercise 4   night on call again
Thr   AM- pre-exercise 5   PM- official exercise (I will be 34 hrs at work when the exercise over...)

I hope tonight will be smooth...

Relief...

Examination...

My colleague went for this ED board exam lately....The result came out and he failed the written test..for the psat few months, he had been studied very hard. I felt sorry for him but it was a relief for him as it was his last trial..

There was no society for emergency medictiine 10+ years ago. Unlike the states or UK, the professional bodies are not named as Colleges. They are called the Society- but they function just like the Colleges for specialty. Most of the Societies practice the "closed system" rule, that means trainee will need to "served" in specific department of certain hospital before he is eligible to sit for exam. There were not much trainning position intially for EM. However it was unlikely to request those ED attending physician/trauma surgeon(who was trained in other specialty and later focus in EM) to go for the resident training program. So the Society of EM(SEM) had allowed those senior doctors who worked in ED for more than 2 years to sit for such exam, but there was a deathline for such exemption - year 2007. I returned to Taiwan in 2003 and I could not fulfil the criteria set. The only way I could sit for such exam was to joined a EM resident trainning program. I was thinking of such option earlier. But the life in ED was so unstable. Although I had the luxury to work 180hrs/month(15 working day),  but I could mostly get a straight 2 days weekend off once per months. As both the kiddo are going to school, spending weekend with them are crucial. In addition to this leave issue, I found that straight night shift for 3 days was my limits. I need few days to recovered from a straight 4 or 5 days night shift. ED life just not my cuppa of tea. That was why I chose to move back to physician life...

The EM resident training program is 3 years unlike the 6 years of British system. But the exposure for EM trainee is inadequate, there was this O+G and ENT, eye attachment, but the duration is short. The EM trainee were unable to master the skill. There was this rumor 1 years ago when my ex-colleague sit for the SEM exam --- The trainess from big hospital stayed in the same hotel 1 night before the exam and they switch questions(provided by their department). As I stressed - it was RUMORS....

I remembered we had this chat with the Consultant Radiologist of Perak at the time I served in Tanjung Malim KK. He came down to "lecture" us for doing Xray for death person. The MO from the hospital side was responsible for the post mortem. Some of the MO just ordered Xray (?skull) for those corpse and the radiographer was pissed off to do so and reported to the Consultant radiologist. He was unhappy with such incidents and came down to give us a good lesson...
It was a Friday evening, the consultant came down with his kids and wife on his car(appearently he was going to KL and claiming part of the mileage..) and give a talk for 15-20+ mins. He described us(doctors with no specialty) are called" Jack of all trade but master of none) in a very sarcastic way. way he talked made me felt that I was one who do not wan to advance...that was another story...

In my mind, an EM physician is more than that - he/she should be Jack of all trade and Master of many(if not all) trade...